(920) The Use of Isoflurane to Reduce Long-Term Sedation Needs and Associated Morbidity in the PICU

Introduction: Pediatric patients with prolonged critical illness often require high doses of sedative and analgesic medications and can experience difficult or prolonged de-escalation from these therapies. Chronic sedation and analgesia use can contribute to accruing additional ICU morbidity, length of stay, and technology or medication dependence upon discharge. Volatile anesthetics, such as isoflurane, are typically utilized in the operating room in pediatrics. In the PICU, isoflurane is used to treat status asthmaticus, status epilepticus, and as a sedative adjunct. There is little data about the most effective duration, dosage, and patient population in which isoflurane can be used as a sedative adjunct in the ICU.

Methods: This is a retrospective case series of pediatric patients < 18 years of age who received isoflurane for sedative wash out while admitted to the intensive care unit of a quaternary care, free-standing children’s hospital from September 2014 to January 2023.

Results: There were 10 cases of isoflurane use for sedation wash out during the study period. Patients had a median age of 16 months (IQR 6-44). Average hospital and ICU length of stay was 1062 days (IQR 791-5206) and 1744 (IQR 791-5206), respectively. The median number of sedative infusions decreased from 3 (IQR 3-3) to 0.5 (IQR 0-2) after completion of isoflurane wash out. The median maximum dose of isoflurane was 1.35 (IQR 1-1.6). Overall in-hospital mortality was high at 30% (3/10), although no patients died while receiving isoflurane. The primary complication during isoflurane administration was hypotension requiring vasoactive agents which occurred in 50% (5/10) of cases.

Conclusions: Isoflurane can be used as an effective sedative adjunct in the ICU for patients with complex sedation needs. Additional research is needed to characterize which patients are ideal candidates for isoflurane washouts, what dose and duration of isoflurane is most effective to reduce sedative and analgesic medication needs, hours of mechanical ventilation, and length of ICU and hospital stay. Finally, long term outcomes in patients who have been treated with isoflurane would help inform a risk benefit analysis when making these clinical decisions in the ICU.